CurrentPennsylvania Insurance DepartmentPolicy N/A

Act 62: Autism Insurance Act Fact Sheet — Coverage Criteria

Customize your policy alerts

Sign up for all Pennsylvania Insurance Department policy alerts

Know when Pennsylvania Insurance Department releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Overview of Pennsylvania's Act 62 requiring many private group health plans, Medical Assistance, and CHIP to cover diagnostic assessment and treatment services for autism spectrum disorder for individuals under age 21, and outlining who and what is covered and treatment requirements.

Policy Summary

PayerPennsylvania Insurance Department

PolicyAct 62: Autism Insurance Act Fact Sheet — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionEnsure services are prescribed/ordered by an authorized licensed clinician and documented in a treatment plan developed by a licensed physician or licensed psychologist.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

under age 21population eligibility age limit

$38,276annual monetary amount (2015)

51+ employeesemployer group size

includes ABAcovered modality

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentPennsylvania Insurance DepartmentPolicy N/A

Act 62: Autism Insurance Act Fact Sheet — Coverage Criteria

Customize your policy alerts

Sign up for all Pennsylvania Insurance Department policy alerts

Know when Pennsylvania Insurance Department releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerPennsylvania Insurance Department

PolicyAct 62: Autism Insurance Act Fact Sheet — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionEnsure services are prescribed/ordered by an authorized licensed clinician and documented in a treatment plan developed by a licensed physician or licensed psychologist.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

under age 21population eligibility age limit

$38,276annual monetary amount (2015)

51+ employeesemployer group size

includes ABAcovered modality

Act 62 Coverage Criteria

Act 62 coverage criteria

Covered services and eligibility under Act 62

Population eligibility: Individual is under age 21 AND is covered under an employer group health insurance policy issued in Pennsylvania to groups of 51 or more employees OR is covered by Medical Assistance OR is covered by CHIP.

Act 62 does not apply to policies issued outside Pennsylvania or to self-funded/ERISA plans.

Service types: Diagnostic assessment and treatment for autism spectrum disorders, including prescription drugs and blood level tests; services of a psychiatrist and/or psychologist (direct or consultation); applied behavioral analysis; and other rehabilitative care and therapies such as speech/language, occupational, and physical therapy.

Coverage is subject to copayment, deductible, coinsurance, and other exclusions or limitations to the same extent as other medical services covered by the policy; some plans may have no cap (annual amount referenced: $38,276 in 2015).

Treatment requirements: Services must be for an ASD, medically necessary, identified in a treatment plan developed by a licensed physician or licensed psychologist, prescribed/ordered/provided by an authorized licensed clinician, and provided by an autism service provider or under their direction.

Licensed behavior specialists (licensed by the Pennsylvania Department of State) may design, implement, or evaluate behavior modification components.

Act 62 does not apply to employer group health insurance policies issued outside of Pennsylvania or to plans that are self-funded or governed by ERISA. The Act applies to children and young adults under age 21 covered by employer group policies issued in Pennsylvania to groups of 51 or more employees, as well as to those covered by Medical Assistance or CHIP.

Services will meet Act 62 coverage only when they are for an autism spectrum disorder (ASD), are medically necessary, and are identified in a treatment plan developed by a licensed physician or licensed psychologist. Services that are not for an ASD, not medically necessary, or not included in an authorized treatment plan do not meet the Act 62 treatment requirements.

Codes, Limits, and Monetary References

Covered services (descriptive list)neutralCovered

No codes listed

Annual monetary limit referenced — Act 62

Annual monetary limit (2015)$38,276

Adjustment noteAmount is adjusted annually; $38,276 is the referenced 2015 figure

ApplicabilityCoverage subject to copayment, deductible, coinsurance, and other exclusions or limitations like other medical services; some plans may have no cap

Provider Authorization, Documentation, and Denial Triggers

Prior Authorization

Prior authorization / provider eligibility

Treatment must be prescribed, ordered, or provided by an authorized licensed clinician (licensed physician, physician assistant, licensed psychologist, licensed clinical social worker, or certified registered nurse practitioner) and must be provided by — or under the direction of — an autism service provider (which includes behavior specialists licensed by the Pennsylvania Department of State).

Authorized clinicians listed: licensed physician, licensed physician assistant, licensed psychologist, licensed clinical social worker, certified registered nurse practitioner.
Autism service provider includes behavior specialists licensed by the Pennsylvania Department of State; services may be delivered by persons or entities working under their direction.

Step Therapy

Step therapy — none specified

This fact sheet does not specify any step therapy protocols, required trials, or sequencing of services; no step therapy specifics are provided.

Background on Autism Spectrum Disorder and Policy Context

Autism spectrum disorder (ASD) is a developmental condition for which early diagnosis and timely treatment can improve outcomes. Act 62 focuses on ensuring access to diagnostic assessment and treatment services for individuals under age 21. Covered services include a range of therapies and medical care when they meet the Act’s treatment requirements and are delivered by authorized providers or under the direction of an autism service provider.

Key Definitions

Applied Behavioral Analysis (ABA)

Coverage statementApplied behavioral analysis (ABA) is listed as a covered treatment for autism spectrum disorders (ASD)

Service contextABA is included among diagnostic assessment and treatment services covered under Act 62

Related servicesABA coverage is listed alongside psychiatric/psychological services, prescription drugs, blood level tests, and other rehabilitative therapies

Autism service provider — definition

Definition — autism service providerIncludes behavior specialists licensed by the Pennsylvania Department of State

ScopeAutism service providers deliver or direct treatment services required by Act 62

Applied Behavioral Analysis (ABA) Coverage and Requirements

ABA coverage and requirements

Coverage and treatment plan requirements related to ABA

ABA coverage: Applied behavioral analysis is a covered service when provided for an autism spectrum disorder and when it meets the Act 62 treatment requirements (medically necessary, included in an authorized treatment plan, prescribed/ordered/provided by an authorized licensed clinician, and delivered by or under the direction of an autism service provider).

Behavior specialists licensed by the Pennsylvania Department of State are included as autism service providers.

Behavioral and Rehabilitative Therapies

Behavioral and rehabilitative therapies

Modalities listed: Includes prescription drugs and blood level tests; psychiatric and psychological services (direct or consultation); applied behavioral analysis; and other rehabilitative therapies such as speech/language, occupational, and physical therapy.